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.- - "� P <br /> Rile, UNIVERSALEI'v1VIRt7NMENTAL <br /> P.O. BOX 996,-BENICIA,CA 94510,(707)747-6699 = ` <br /> NON-HAZARDOUS SPECIAL WASTE MANIFEST <br /> 'k GENERATOR ,'Ta � <br /> Generator Name Generating Location'' <br /> Address . goo- Vict6r pw� Address ti <br /> j <br /> Lodi, GA 95240 # <br /> 10 19 - �� �i <br /> Phone No. Phone No. -1 l <br /> '3 <br /> Containers Type " <br /> Description of WasteI Quanti. Units Na. T e D- Drum_." <br /> _51C-Carton B - BBag <br /> tart ariTiated S ,11It h Vuel a oils T -Truck <br /> I ❑ m P -Pounds• } <br /> Y-Yards <br /> ❑ m � Q• Other <br /> t <br /> I hereby certify that the above named material does not contain free'liquid as"definedby 40 CFI Part 260,10 or,any applicable <br /> l state law, is not a hazardous waste as defined by 40 CFR Part 261'or any applicable state law, has been properly described, <br /> classified and packaged, and is in proper condition for transportation according to applicable regulations.Ci <br /> . IEEE= <br /> ,f : l� � <br /> -i I <br /> Generator Authorized Agent Name Signature ' 7 Shipment Date <br /> TRANSPORTER <br /> Truck No r j .�R" Phone No. 707-.7,47-6699 <br /> Transporter Name Driver Name (Print) <br /> Address 1698 Park Itoa:d ?l �AN <br /> � �, ,z���.,.. <br /> Vehicle License No./State a <br /> { 'I <br /> .id Vehicle Certification <br /> I hereby certify that the above named material was picked up I hereby certify that the above named material was delivered with- <br /> at the generator site listed above. out incident to the d4stination listed below. <br /> i <br /> i Y �4.:.+ Y �...Y..�' r>w.w,•.. la:r � '� x •. 4 4� .7 <br /> Al <br /> - <br /> { Driver Signature Shipment Date Drivirsignature"y!' Delivery Date <br /> DESTINATION <br /> Site Nameo�rt`d �xt1 l Phane Na.', ' "" _s ;sa °� <br /> } �J10 Charter Wal �` �.ckt-qn, Cir 5206 i <br /> Address : - <br /> F <br /> I'"Qby,certify that the above named material has been accepted and tD.ahe best of rI knowledg0 the foregoing•is true.and accurate: } <br /> fff� <br /> -� 4 i .1 ' ,k,-,.ref ,_ Pf ?� },r+„�.!'� 4 f f` s� r f 1 ` } <br /> I Name of Authorized_Agent Signature ' <br /> - - — — g Aeceipl Date" <br />